
          <form method="post" action='<?php echo site_url("/members/register_post");?>' style="margin:0px" accept-charset="utf-8">
              <input type="hidden" name="next" value="1" />
              <table cellspacing="0" cellpadding="4" style="border:0px;width:100%">

                    <tr>
                        <td style="width:30%" align="right"><b>First Name</b></td>
                        <td style="width:70%">
                            <input name="first" type="text" style="width:200px" value="" maxlength="255" />
                        </td>
                    </tr>

                    <tr>
                        <td align="right"><b>Last Name</b></td>
                        <td>
                            <input name="last" type="text" style="width:200px" value="" maxlength="255" />
                        </td>
                    </tr>

                    <tr>
                        <td align="right"><b>Username</b></td>
                        <td>
                          <div><small>( 4-25 characters )</small></div>
                          <input name="username" type="text" style="width:200px" value="" maxlength="25" />
                        </td>
                    </tr>

                    <tr>
                        <td align="right"><b>Password</b></td>
                        <td>
                          <div><small>( 4-25 characters )</small></div>
                          <input name="password" type="password" style="width:200px" value="" maxlength="25" />
                        </td>
                    </tr>

                    <tr>
                        <td align="right"><b>Password Again</b></td>
                        <td>
                          <input name="password2" type="password" style="width:200px" value="" maxlength="25" />
                        </td>
                    </tr>

                    <tr>
                        <td align="right"><b>Birthday</b></td>
                        <td>
                          <input type="date" name="birthday" maxlength="255" style="width:200px" type="text" value="" />
                        </td>
                    </tr>        

                    <tr>
                        <td align="right"><b>E-mail</b></td>
                        <td>
                            <input name="email" type="text" style="width:200px" value="" maxlength="255" />
                        </td>
                    </tr>

                    <tr>
                        <td align="right"><b>E-mail Again</b></td>
                        <td>
                            <input name="email2" type="text" style="width:200px" value="" maxlength="255" />
                        </td>
                    </tr>

                    <tr>
                        <td></td>
                        <td style="padding-top:20px"><b>Mailing Address</b></td>
                    </tr>
                                
                    <script type="text/javascript">
                        function updatebillingState()
                        {
                            var selObj = document.getElementById('billingCountry');
                            var selIndex = selObj.selectedIndex;
                            if(selObj.options[selIndex].id=='_state')
                              showByID('billingState');
                            else
                              hideByID('billingState');
                        }
                    </script>

                    <tr>
                        <td align="right"><b>Address 1</b></td>
                        <td>
                          <input name="billingAddress1" maxlength="255" style="width:200px" type="text" value="" />
                        </td>
                    </tr>

                    <tr>
                        <td align="right"><b>Address 2</b></td>
                        <td>
                          <input name="billingAddress2" maxlength="255" style="width:200px" type="text" value="" />
                        </td>
                    </tr>

                    <tr>
                        <td align="right"><b>City</b></td>
                        <td>
                          <input name="billingCity" maxlength="255" style="width:200px" type="text" value="" />
                        </td>
                    </tr>

                    <tr id="billingState">
                        <td align="right"><b>State/Province</b></td>
                        <td>
                            <select name="billingState">
                            <?php 
                                foreach ($states as $state) {
                                  
                                  echo "<option value='$state->id'>" . $state->name ."</option>";
                                }// end foreach
                            ?>
                            </select>
                        </td>
                    </tr>

                    <tr>
                        <td align="right"><b>Country</b></td>
                        <td>
                            <select name="billingCountry" onchange="updatebillingState();" id="billingCountry">
                            <?php 
                                    echo "<option id='_state' value='222'>United States</option>";

                                    foreach ($countries as $country) {
                                      
                                        if ($country->id == 222 || $state->id == 38) {
                                          echo "<option value='$country->id' id='_state'> $country->name</option>";
                                        } else {
                                          echo "<option value='$country->id' > $country->name</option>";
                                        }
                                        
                                    }// end foreach
                            ?>        
                            </select>

                            <script type="text/javascript">
                              <!--
                                updatebillingState();
                              -->
                            </script>
                        </td>
                    </tr>

                    <tr>
                        <td align="right"><b>Zip/Postal Code</b></td>
                        <td>
                            <input name="billingZip" maxlength="10" style="width:50px" type="text" value="" />
                        </td>
                    </tr>

                    <tr>
                        <td></td>
                        <td style="padding-top:20px"><b>Additional Fields</b></td>
                    </tr>
                    
                    <tr>
                      <td align="right"><b>PayPal Email Address</b></td>
                      <td>
                          <div>
                              <small>PayPal Email Address -- Must be set to receive PayPal payments</small>
                          </div>
                          <input name="cust2" value="" type="text" maxlength="255" style="width:200px" />
                      </td>
                    </tr>
                    
                    <tr>
                      <td align="right"><b>PayZa E-Mail Address</b></td>
                      <td>
                           <div>
                                <small>PayZa Email address - Must be set to receive PayZa payments</small>
                            </div>
                            <input name="cust3" value="" type="text" maxlength="255" style="width:200px" />
                      </td>
                    </tr>

                    <tr>
                        <td></td>
                        <td style="height:20px"></td>
                    </tr> 

                    <tr>
                        <td></td>
                        <td>
                            <label>
                              <input type="checkbox" name="terms" value="1" checked /> I have read and agreed to the 
                                <a href="http://pointdollars.com/members/terms.php" target="_blank">
                                  <b>Terms and Conditions</b>
                                </a> of Point Dollars.
                              </label>
                        </td>
                    </tr>

                    <tr>
                        <td></td>
                        <td>
                            <input type="submit" value="Register">
                        </td>
                    </tr>

              </table>
          </form>
						
	       <br />